In this study, we found that most hip fracture patients (58%) were discharged to a nursing facility, which is significantly higher than the 25%–35% reported by other investigators (42
). However, when we evaluated placement at 90 days and 180 days for those patients initially discharged to a nursing facility, half (49%) were at home at 90 days and were also there at 180 days (96%). Thus, even though many hip fracture patients are initially discharged to a nursing facility, long-term stays are uncommon, with most patients returning to their homes within 90 days. These results suggest that evaluation of the entire hip fracture episode of care provides a more complete picture of the aftermath and should be considered when identifying ways to reduce morbidity and mortality. Initial discharge to home and inpatient rehabilitation decreased over time, while nursing facility placements increased. These trends reflect 2002 changes in Medicare reimbursement policies (28
) and the aging of the AHEAD cohort. The absence of entries in for 2 of the inpatient rehabilitation categories (inpatient rehabilitation and long-term acute care hospitals) and 2 of the nursing facility categories (swing beds and other nursing facilities) from 1993 to 2001 also reflects those Medicare policy changes.
In-hospital mortality was 2.7%, which is close to a recent report of 1.6% but somewhat lower than the 4%–5% found in older reports (12
). These differences probably reflect shortened hospital stays resulting from the implementation of the prospective payment system (45
). Our 6-month mortality rates (19%) were substantially higher than the 12%–14% previously reported for 6-month mortality (14
). Of note in our multivariable analyses of mortality are the strong effects of frailty, age, and dementia on postfracture mortality. While these results concur with those of prior reports (12
), measures of self-reported health and cognition were not statistically significant predictors when evaluated concurrently with claims-based assessments of cognitive status (admission diagnoses).
The most important contribution of this study is its prospective objective assessment of change in functional status. To our knowledge, no other study on the aftermath of hip fracture has had functional status self-assessments obtained prior to the experience of hip fracture without retrospective reporting bias. Meaningful functional status declines after hip fracture were common and substantial. To provide perspective, we compared the functional status changes of hip fracture patients to the average wave-to-wave within-person changes among AHEAD participants who did not experience hip fracture. The results demonstrated that the functional decline of hip fracture patients was generally 3 times larger than that for non-hip-fracture patients. Thus, while it is important to identify ways to prevent hip fracture in older adults, it is equally important to address the functional needs of hip fracture patients.
Although our sample was nationally representative and comparable in size to those of several recent cohort reports, we had smaller samples in our assessment of functional status changes. This was due to the considerable 1-year postfracture mortality and the increased use of proxy respondents at postfracture interviews. Therefore, our functional status change results probably underestimate the impact of hip fracture, because our sample probably contained only the healthiest and least impaired subset of hip fracture patients.
As shows, while declines in functional status after a hip fracture were substantial, a potential limitation to the interpretation of these results is whether persons who suffered a hip fracture were in declining health prior to their hip fracture. Declining functional status could have led to the hip fracture event. However, based on our post-hoc analysis of functional status during the time period prior to the hip fracture, the marked declines in functional status after a hip fracture were most likely due to the hip fracture event and not to pre-hip-fracture declines.
Our study was not without limitations. In addition to the functional status sample size issues, we did not use a control group in the traditional sense. Instead, we relied on having pre- and post-hip-fracture data and using each patient as her or his own control. Finally, although we used reliable and valid measures of functional status pre- and post-hip-fracture, no clinical performance measures were available to provide more granular assessments.
In conclusion, our results suggest that previous studies may not have fully captured the deleterious effect of hip fracture on discharge placement, functional status, and mortality. While additional efforts to avoid hip fracture and limit its adverse effects continue to be needed, efforts to identify the recuperative needs of hip fracture patients are also important for the successful aging of older adults.